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GULF VETS Gulf Review

Vol. 12, No. 1 Information for Veterans Who Served in Desert Shield/Storm November 2003

New VA Study Supports Service- Exercise/Behavioral Therapy Helps Gulf War ALS Link Veterans A recent scientifi c study supports a 22-month A Department of Veterans Affairs-sponsored study policy by the Department of Veterans Affairs (VA) to to determine if aerobic activity and chronic behavior recognize amyotrophic lateral sclerosis (ALS) among therapy (CBT) could improve the symptoms of Gulf veterans of the Gulf War as a service-connected War veterans found that modest relief for some of the illness. symptoms in physical and mental health functions, but “Based upon preliminary research available in no improvements in pain symptoms. CBT is a widely December 2001, I felt it was appropriate for us to act used technique for bringing some relief to patients with swiftly,” said Secretary of Veterans Affairs Anthony otherwise diffi cult to treat symptoms. J. Principi. “I’m gratifi ed that the fi nal study supports Researchers from the Boston VA Medical Center, that decision.” ALS, or Lou Gehrig’s disease, kills the University of Michigan, and the Walter Reed cells in the brain and spinal cord that control muscle Army Medical Center led the study, a randomized trial movement, resulting in gradual wasting of the muscles. conducted at 18 VA medical centers and two military Fatal in most cases, the disease usually strikes people hospitals from April 1999 to September 2001. between ages 40 and 70 years of age. The cause of the The randomized study included 1,092 patients who disease is unknown. suffered from at least two chronic symptoms present The recent study found that veterans who were among many Gulf War veterans: fatigue that limits deployed to the combat theater during the Gulf War (Continued on page 2) were nearly twice as likely to develop the disease as veterans not deployed to the Gulf. Forty cases Also in This Issue were identifi ed among Gulf War veterans. Based on Studies Confi rm Poorer Cognitive Performance in comparison to non-deployed Gulf War era veterans, 33 Gulf War Veterans…...…….…...... ….…...….…...... 2 cases were expected in this group. Therefore, seven Dep. Under Secretary for Health Perlin Testifi es additional cases were found among approximately 700,000 Gulf War veterans. The incidence of ALS Before Congress on Pre- and Post-Combat was especially high among deployed Air Force Deployment Health Issues…..…..……………....…..3 personnel, who were 2.7 times more likely to develop GAO Questions DoD Plume Modeling……………..6 ALS than non-deployed Air Force personnel. Research Advisory Committee Continue to Meet “Earlier research did not provide a defi nitive Regularly ..………...….….…...….…..…...….…...... 7 answer to this issue,” said lead author Ronnie D. Horner, Ph.D. Horner was with VA’s Epidemiologic NAS/IOM Gulf War Ongoing Health and Research and Information Center in Durham, NC, Environmental Exposure Assessments ...….….....….7 when the research was conducted, and is now with About the “Review”....…………...... …...... …8 the National Institute of Neurological Disorders and Stroke of the National Institute of Health. “We now VA Publishes Brochure for Operation Iraqi have compelling evidence that service in the Gulf is Freedom Veterans and Their Families...……...…....8 associated with the occurrence of ALS among veterans Address Changes and Duplicates....……...…..…….9 of the ’90-‘91 Gulf War.” The study, published in the September 23, 2003, issue of the scientifi c journal Gulf War Health Registry Examination Statistics....9 Neurology and funded by VA and the Department Q’s and A’s - New Information Regarding Birth of Defense (DoD), does not identify a cause for the Defects...... ………...... ……………………...…....10 disease or the increased occurrence in this group of Where to Get Help……………....……….…..……11 veterans. (Continued on page 2) 1 Department of Veterans Affairs New VA Study Supports Gulf War Service- Drawbacks of the study included noncompliant ALS Link (Continued from page 1) patients (patients dropping out of the study), including The ALS Association and researchers from the an average of only 50% attendance of the 12 weekly Centers for Disease Control and Prevention advised the therapy sessions. Patients who attended more than study leaders. Numerous medical, academic, veterans eight of 12 weekly sessions reported significant and voluntary health organizations provided assistance improvement in physical functioning than those who in conducting the study. attended fewer sessions. The study, “Cognitive Behavior Therapy and Another recent study by Dr. W. Haley of Aerobic Exercise for Gulf War Veterans’ Illnesses: the University of Texas Southwestern Medical Center A Randomized Control Trial,” was published in the at Dallas also supports VA’s decision to officially March 19, 2003, issue of the Journal of the American recognize ALS as a service-connected illness for VA Medical Association. benefits. The above article was drafted by Julissa Cruz, a VA’s National ALS Registry senior majoring in journalism at the University of Il- Earlier this year, VA established a national ALS linois at Ubana-Champaign. Julie spent 10 weeks in registry to identify veterans with the disease -- VA's Environmental Agents Service as a summer intern regardless of when they served -- and track their health through the Hispanic Association of Colleges and status. Veterans with ALS who enroll will complete Universities (HACU) National Internship Program. an initial telephone interview covering their health and militaryservice and will be interviewed twice yearly thereafter. Studies Confirm Poorer Cognitive Performance in Gulf War Veterans For more information about VA’s ALS Registry, based at the Durham VA Medical Center, call 1- Veterans deployed to the Gulf War in 1990 and 877-DIAL-ALS (1-877-342-5257) or email. 1991 scored worse overall on neuropsychological [email protected] tests compared to non-deployed veterans in a series of studies conducted by researchers at the Department of It is important to keep in mind that ALS is a very Veterans Affairs (VA) Environmental Hazards Center. rare disease, and that 40 cases diagnosed among the The Environmental Hazards Center is part of the VA nearly 700,000 veterans who served in the theater of Boston Healthcare system. The five studies appear in operations in 1990-91 suggests that veterans are still the June 2003 issue of the Journal of Psychopathy and very unlikely to get this fatal disease. Behavioral Assessment. Exercise/Behavioral Therapy Helps Gulf War In one study, Gulf War-deployed veterans performed Veterans (Continued from page 1) significantly worse than their non-deployed cohorts on tests of attention, visuospatial skills, visual memory, usual activity, musculoskeletal pain, and/or cognitive and mood. Among the deployed veterans, those who symptoms such as memory loss or concentration reported having taken pyridstigmine bromide – a pill difficulties. given to about 250,000 Gulf War personnel to protect The study found that CBT, whether or not it was against possible attack with nerve gas – performed combined with aerobic activity, led to significant worse than those who reported not taking the pill. improvements in physical functioning after 12 months. Past research on Gulf War veterans has shown Among the patients receiving CBT, there was an that they are an increased risk for a vague cluster 18.3% increase versus the patients not receiving CBT of symptoms, sometimes called Gulf War illness, who only improved 11.6%. involving chronic fatigue, musculoskeletal problems, CBT also helped improve mental health functioning asthma, post-traumatic stress disorder, depression, and cognitive symptoms regardless of aerobic activity. memory loss, poor concentration, and other health Aerobic activity, with or without CBT, also led to problems. These problems are also diagnosed in non- improvements in mental health functioning, cognitive Gulf War veterans, although usually at lower rates. symptoms, fatigue and distress. There is still no definitive answer regarding the cause However, neither improved any pain symptoms. of these various symptoms. Theories point to stress and other psychological factors, exposure to chemical

2 or infectious agents, or other environmental toxins, or health care, unless there is sufficient medical evidence side effects of anti-. to conclude that the illness is not attributable to that Another of the five studies showed that symptoms service. of post-traumatic stress disorder were more prevalent To date, 22 combat veterans have been transferred in Gulf-deployed veterans, and that these symptoms to VA from DoD for specialized, long-term health were associated with poorer neuropsychological care and rehabilitation. These patients have had performance. spinal cord injuries, gunshot and grenade wounds, and other combat trauma. There have been relatively According to Roberta F. White, Ph.D., collaborator few veterans of Operation Iraqi Freedom who have on four of the five articles and author of the fifth otherwise presented for care at a VA medical center – a review of existing research – there appears to be because most combatr troops are stil serving in multiple causes of Gulf War veterans’ illnesses. She or remain on active duty. The Iraqi war veterans commented, “The neuropsychological and health presenting to our clinics have had a varied range symptom sequelae of Gulf War zone service are multi- of health problems. No illness due to chemical or determined and cannot easily be explained on the biological agents have been reported. basis of simplistic models of causation.” She added, “Psychological, historical, and exposure parameters Assessment of Difficult-to-Diagnose Illnesses must be considered in the scientific evaluation of this The majority of veterans returning from combat and problem.” peacekeeping missions are able to make the transition Perlin Testifies on Pre- and Post-Deployment to civilian life with few problems. Most who come to Health Issues for care at a VA medical center because most combat troops are still serving in Iraq or remain on active duty. On July 9, 2003, Jonathan B. Perlin, M.D., Ph.D., The Iraqi war veterans presenting to our clinics have Deputy Under Secretary for Health, Department had a varied range of health problems. No illnesses of Veterans Affairs, testified on Pre- and Post- due to chemical or biological agents have been Deployment Health Issues before the House Committee reported. on Veterans’ Affairs Subcommittee on Oversight and Investigations. Here is his prepared statement. Assessment of Health Care Needs Because over 200,000 U.S. troops have been In addition to providing high-quality health care engaged in Operation Iraqi Freedom, I am grateful for veterans, VA now has the capability to collect for the opportunity to emphasize that VA is prepared and analyze comprehensive health information with to provide high quality health care and disability its computerized outpatient and inpatient medical assistance to Iraqi Freedom veterans. Since the Gulf records. The capability to assess the health status of War in 1991, VA has developed and implemented veterans has been greatly improved since the Gulf improved policies and programs to care for our War. Standard health care databases help VA evaluate Nation’s newest war veterans. As we have all specific health questions. Importantly, VA clinicians witnessed over the last couple of months, this conflict are able to review veterans’ prior treatment in VA is not over, and our men and women in uniform remain when the veterans obtain care from the Department. in harms way and deserve our best efforts. This capability will support broad, long-term, and comprehensive assessment of health status because Health Care, Surveillance, many veterans return frequently for VA health care Education, and Outreach and are often seen in different clinics, and may Health Care Following Combat be evaluated in different parts of the country for It is critical to provide high-quality health care after specialized health care needs. every war. Congress understands this and under 38 VA is working with DoD to obtain a roster of recent U.S.C. § 1710(e)(1)(D), added by Public Law 105- combat veterans to facilitate analysis of computerized 368, VA was authorized to provide health care for a health records. Furthermore, veterans of Operation 2-year period to veterans who serve on active duty in Iraqi Freedom are eligible for evaluation in the Gulf a theater of combat operations during a period of war War clinical registry. Every Iraqi Freedom veteran after the Gulf War, or in combat against a hostile force is being offered an opportunity to participate in this during a period of hostilities after November 1, 1998. registry, which provides a thorough clinical evaluation Consequently, combat veterans, like those now serving and documentation of symptoms and potential in Iraq, have a 2-year period of access to free VA exposures. 3 Supplementary Clinical Programs which are problems following all . Health care at the centers is available to veterans of all eras -- VA is developing a new clinical reminder that will including recent war veterans -- through referral by pop up on the computer screens of VA health care primary VA health care providers. The two centers providers when they encounter a new patient who may also provide research into better treatments and be a veteran of the war in Iraq or . This diagnoses, develop educational materials, and develop clinical reminder will ensure that health care providers specialized health care programs to meet veterans’ evaluate veterans for deployment-related medical and unique needs. More information on the WRIISC’s psychological risks. It will also provide Internet links can be found at the VA website, www.va.gov/ with relevant clinical practice guidelines and exposure environagents. health risk information. Veterans Health Initiative In addition, the VA Followup Program at the Baltimore VA Medical Center is VA has built upon the lessons learned from our coordinating screening of the urine of veterans experiences with Gulf War and Vietnam veterans’ who may have been exposed to depleted uranium programs to implement innovations and improved duringOperation Iraqi Freedom. The service is being approaches to health care for all veterans. The provided to both VA patients and to the Defense Veterans Health Initiative (VHI) is a comprehensive Department for active duty troops. The results of this program designed to improve recognition and treat- testing are provided directly to the veteran and their ment of deployment health effects, to better document VA or DoD physician. veterans’ military and exposure histories, and to establish a database for further study. Ensuring High Quality Post-Deployment Health Care The education component of the VHI prepares VA Specialized health care during the post-deployment health care providers to better serve their patients. VA period can help prevent long-term health problems. has completed modules on spinal cord injury, cold Therefore, VA and DoD developed evidence-based injury; traumatic amputation, Agent Orange, the Gulf clinical guidance for treating veterans following War, Post-Traumatic Stress Disorder, ex-POW health deployment. Clinical Practice Guidelines (CPG’s), effects, blindness/visual impairment hearing loss, which are based on the best scientifically supported and, radiation. We are currently developing modules practices, give health care providers the structure, on infectious disease health risks in Southwest , clinical tools, and educational resources they need sexual trauma, traumatic brain injury, health effects to diagnose and manage patients with deployment- from weapons of mass destruction, and occupational related health concerns. VA and DoD have developed lung diseases. These important tools are integrated two post-deployment CPG’s: a purpose with other VA educational efforts to enable VA Post-Deployment CPG and a CPG for unexplained practitioners to more quickly and accurately arrive at fatigue and pain. Our goal is to make sure that all VA a diagnosis and to provide more effective treatment. health care providers are well-informed about specific [The VHI Web site is www.va.gov/VHI.] deployments and related health hazards. Information on these Clinical Practice Guidelines is available Enhanced Outreach online at www.va.gov/environagents. Veterans and their families, elected representatives, VA for health care receive conventional diagnoses the media, and all need timely and reliable and return to civilian life, and a small percentage information about wartime health risks. Consequently, of them develop difficult-to-diagnose symptoms. VA has developed two brochures that addresses the Sustained clinical care and research is needed to main health concerns for in Afghanis- understand post-deployment health problems. tan and Iraq. These brochures answer health-related Consequently, VA has established two “War-Related questions that veterans, their families, and health Illness and Injury Study Centers” (WRIISC’s), in care providers may have about these hazardous East Orange, NJ, and Washington, DC, to provide deployments. They also describe relevant medical care specialized health care for veterans from all combat programs at VA. These two brochures can be accessed and peacekeeping missions who suffer difficult-to- at: diagnose but disabling illnesses. • http://www.va.gov/environagents/ docs/afghanVet302.pdf for the war in VA’s two WRIISC’s focus on determining the causes Afghanistan. and most effective treatments for chronic symptoms,

4 Another challenge for outreach is to address the diagnose illnesses. Under 38 U.S.C. § 1117 (as specific concerns of veterans and their families over amended by Public Law 107-103), VA has authority the potential long-term health impact of environmental to compensate Gulf War veterans for chronic exposures during deployment. These concerns are disabilities resulting from an undiagnosed illness or addressed through newsletters and fact sheets to certain medically unexplained chronic multi-symptom veterans covering health and compensation issues, illnesses. Service members who serve in the Southwest including environmental health risks; regular briefings Asia Theater of Operations during the current conflict of veterans service organizations; national meetings on with Iraq will also be eligible for compensation for health and research issues; media interviews; and, other disabilities resulting from undiagnosed illnesses under educational material and Web sites with information, this authority. like www.va.gov/environagents. Research Very importantly, VA recently published -- in VA places a high priority on the development collaboration with DoD -- a new brochure called “A of improved methods of diagnosis, treatment, and Summary of VA Benefits for National Guard and prevention of illnesses related to deployments. Reservists Personnel.” This brochure does an excellent In October 2002, VA’s Office of Research and job of summarizing the benefits available to this special Development released a program announcement on population of veterans upon their return to civilian life. deployment health research to expand VA’s research Too often Reservists and National Guard personnel portfolio on long-term health effects of hazardous have not received timely information about the benefits deployments, such as the Gulf War, Bosnia/Kosovo, they have earned. A million copies of this brochure Afghanistan, and the current war in Iraq. Up to are being printed and distributed. This brochure is also $20 million will be spent on research to evaluate available online at: http://www.va.gov/environagents/ deployment health hazards. The results of this research docs/SVABENEFITS.pdf. program should provide useful guidance in improving Recruit Assessment Program (RAP) the medical care of veterans who return from combat, VA is committed to the development of a lifelong and in improving preventive medicine efforts during health record for all military personnel and veterans. future deployments. Therefore, VA is supportive of DoD’s efforts to Coordination with the Deployment of Defense develop and implement the Recruit Assessment Deployment Health Work Group Program (RAP) that will collect comprehensive baseline health data from U.S. military recruits. One of the important lessons learned since the Gulf War was the need for continuous and formal VA Vet Center Program intergovernmental coordination among VA, DoD, VA’s Vet Centers, originally conceived to provide and the Department of Health and Human Services a wide variety of readjustment services to Vietnam (HHS). As a result, the Deployment Health Work veterans, have been invaluable in providing similar Group of the VA-DoD Health Executive Council was services to veterans from more recent combat and established in 2002 to ensure interagency coordination peacekeeping missions. More than 115,000 veterans for all veteran and military deployment health issues. of the Gulf War have made use of their services. The Governmental coordination will play a critical role in VA Vet Centers are now ready to help veterans of the addressing health problems among veterans in future current hostilities in Iraq. conflicts and peacekeeping missions. This work Disability Compensation group has met repeatedly during the recent conflict in Iraq to coordinate government efforts, such as the To assist in disability evaluations, VA has actively development of a roster of deployed troops. worked with DoD to implement a standardized separation physical examination that thoroughly Transmission of Health Data between DoD and VA documents a veteran’s health status at the time of VA and DoD are closely collaborating to develop the separation from military service and that also meets capability to share medical information electronically. the requirements of the physical examination needed Recently, the VA/DoD Joint Executive Council and by VA in connection with a veteran’s claim for Health Executive Council approved the adoption of compensation benefits. the Joint VA/DoD Electronic Health Records Plan. Additionally, VA has worked to provide fair This plan provides for the exchange of health data and compensation for Gulf War veterans with difficult-to- development of a common health information 5 infrastructure supported by common data Keith Rhodes, GAO’s Chief Technologist at the communications, security and software standards. Center for and Engineering, Applied This will allow interoperability of DoD and VA high Research and Methods, offered this assessment, performance health information systems. Since June preliminary findings, during testimony presented at 2002, VA providers have had online access to health a hearing entitled “Following Toxic Clouds: Science information from DoD’s Composite Health Care and Assumptions in Plume Modeling,” before the System for discharged and retired service members. House Government Reform Subcommittee on National Deployment Health Security, Emerging Threats, and International Relations on June 2, 2003. VA applauds the efforts of DoD to prevent health problems among deployed troops and to provide When the issue of possible exposure of U.S. military immediate care for combat casualties. DoD has personnel was raised in 1993, DoD and the Central made substantial progress in lowering morbidity and Intelligence Agency (CIA) concluded that no U.S. mortality rates on the . Nevertheless, we troops were exposed to these agents because (1) there have to focus greater attention on the long-term health were no forward-deployed agents, problems of veterans that occur after every war. The and (2) plumes-clouds of chemical warfare agents trauma of warfare has lasting effects. The physical and from the bombing could not have reached these troops. psychological wounds of war heal slowly, and toxic In 1996, when it became known that in March exposures on the battlefield may have enduring health 1991, after the , U.S. troops destroyed a consequences long after the actual war has ended. stockpile of chemical munitions at the The key to addressing the long-term needs of storage site in southeastern Iraq, that position changed. veterans is improved medical recordkeeping and Consequently, DoD and the CIA made several environmental surveillance. VA therefore is actively modeling efforts to estimate the number of troops engaged with DoD in obtaining as much deployment that might have been potentially exposed to low-level health and exposure information as possible, including chemical warfare agents. data on troop locations and data collected as part of Since the actual data, such as the quantity and purity pre- and post-deployment health screening. (concentration) of the agents, and meteorological Summary conditions (including wind and weather patterns) were not available, DoD and CIA conducted field testing A veteran separating from military service and and modeling of bombing sites in 1996 and 1997 to seeking assistance today from VA will receive determine the size and path of the plume, as well as the improved health care and disability assistance. VA number of U.S. troops exposed to the plume. has successfully developed new programs and adapted many existing programs for the benefit of DoD also asked the Department of Energy’s combat veterans. VA also has significant experience Lawrence Livermore National Laboratory to conduct with the special provisions in law authorizing modeling. In 1997, DoD and CIA also combined disability compensation for war veterans with a number of their own modeling efforts into a unexplained symptoms. In collaboration with other composite and conducted additional plume modeling. Federal agencies, VA has initiated new programs Subsequently, in 2000 the modeling of Khamisiyah for developing and coordinating Federal research was revised. on veterans’ health questions. The Department of Plume models serve as a basis for estimating Veterans Affairs is committed to helping ensure the the exposure after chemical warfare agents were health of service members both during deployment and released into the environment. In making this model, after they leave military service. mathematical equations were used to predict how much GAO Questions DoD Plume Modeling and in what direction the plume traveled. The GAO concluded that because the DoD did not have accurate The General Accounting Office (GAO) concluded information about the source of chemical warfare in testimony before Congress that the Department agents nor weather conditions, the plume model could of Defense (DoD)-created plume models were not accurately predict where the chemical plume not definitive in determining who was exposed to was. Because the DoD did not have the appropriate low levels of chemical warfare agents accidentally meteorological conditions and source term information, released following the demolition of Iraqi weapons at the GAO felt the DoD’s results should not determine Khamisiyah, Iraq, in March 1991, after the Gulf War how much troops were exposed to during the Gulf War. ceasefire. 6 The GAO also felt that the models were not fully birth defects, neurotoxins, ALS (Lou Gehrig’s developed and showed certain biases that led to Disease), anthrax, and other matters. During the particular results. According to the GAO testimony, first day of this meeting, VA researcher Han Kang there were also certain situations that were excluded presented information from the VA’s National Health from the model, including but not limited to, plume Survey of Gulf War Veterans and Their Families that height and exposure duration. For example, using shows an association between the children’s birth different assumptions, the exposure footprints might defects and their parents’ military service in the Gulf have been larger and covered more areas where troops War. While the Associated Press and other were stationed. However, it is unlikely that more media entities reported the finding, it has not yet been models could be more helpful because of limited peer-reviewed or published in a scientific journal, information. steps required to gain acceptance in the scientific Because of these flaws, the GAO felt that the plume community. (Occasionally, scientific papers undergo model was unrealistic and inappropriate. Although extensive changes during this process as methodologies there were some uncertainties that arose from the are carefully analyzed, assumptions challenged, and model created by the DoD and the CIA, the results conclusions modified.) were still used to determine whether or not soldiers The Committee, authorized by Congress in 1998, is were exposed to chemical agents. The GAO claimed required to make recommendations to the Secretary that the DoD model should not be considered valid of Veterans Affairs on research relating to the health because of the various weaknesses. consequences of military service in the Southwest Asia GAO’s full testimony is available at www.gao.gov/ theater of operations during the Gulf War. cgi-bin/getrpt?GAO-03-833T. For further information Committee meetings are open to the public and about the testimony, contact Keith Rhodes at include time reserved for public comments. The [email protected]. Committee welcomes and solicits information This article was drafted by Julissa Cruz, a senior concerning medical research regarding Gulf War majoring in journalism at the University of Illinois veterans’ illnesses from physicians, scientists, veterans, at Urbana-Champaign. Julie served in VA’s members of the general public, and other interested Environmental Agents Service as a summer intern parties. through the HACU National Internship Program. Mr. James H. Binns, Jr., former Chairman, Parallel Research Advisory Committee Continue to Design, Inc., Tempe, AZ, and former Principal Deputy Meet Regularly Assistant Secretary of Defense, chairs the 11-member Committee. On June 16-17, 2003, and October 27-28, 2003, the These were the fifth and sixth meetings since Research Advisory Committee on Gulf War Veterans’ Secretary of Veterans Affairs Anthony J. Principi Illnesses met in Washington, DC, to hear reports activated the Committee early last year. Earlier concerning completed and ongoing research initiatives meetings were held in April, June, and October 2002, and discuss future research efforts. and February 2003. Secretary Principi regularly At the June meeting, the Committee received attended part of the meetings. reports from Antonio Sastre, Ph.D., Midwest Research The Committee Web site is www.va.gov/rac-gwvi. Institute, Kansas City, MO; Roberta White, Ph.D., The e-mail address is RAC [email protected]. Boston Environmental Hazards Center, Boston, VA The mailing address is RAC-GWVI, 3366 N. Torrey Healthcare System Medical Center, Boston, MA; Pines Court, Suite 250, La Jolla, CA 92037. The John Vogel, Ph.D, Lawrence Livermore National telephone number is 858-453-1058. The fax number is Laboratories, Lawrence, CA; Rogene Henderson, 858-453-1076. Ph.D., Lovelace Respiratory Research Institute, Albuquerque, NM; Nelda Wray, M.D., Chief Research NAS/IOM Gulf War Ongoing Health and and Development Officer, Department of Veterans Environmental Exposure Assessments Affairs; and Jennifer Vasterling, Ph.D., VA Medical Public Laws 105-277 and 105-358 directed VA to Center, New Orleans, LA. seek to enter into a contract with the National Academy In the October meeting, the Committee continued to of Sciences (NAS) for an independent review of the receive reports from scientists at VA, Department of medical/scientific information regarding the Defense, and non-governmental researchers regarding (Continued on page 9)

7 About the Review VA Publishes Brochure for Operation Iraqi The “Gulf War Review” is prepared by the VA’s Freedom Veterans and Their Families Environmental Agents Service (EAS). The “Review” In May 2003, the Department of Veterans Affairs is published to provide information about the concerns (VA) published a six page brochure, entitled “IRAQI of Gulf War veterans, their families, and others FREEDOM VETERANS – Information for interested in possible long-term health consequences Veterans who Served in Southwest Asia in 2003— of military service in the Gulf War. The “Review” Health Care and Assistance for U.S. Veterans of describes actions by VA and others to respond to these Operation Iraqi Freedom. concerns. For past and current issues of the “Review” This 8 1⁄2 x 11 inch brochure focuses on the major and additional information, see our Web site at health concerns related to military service during 2003 www.va.gov/gulfwar. in Iraq, , and surrounding areas, and answers The most recent issues of the newsletter are dated questions that veterans, their families, and health October 2002 and July 2003. Additional issues will be care providers may have about this deployment. It prepared when warranted by significant developments. also describes medical care programs that VA has EAS anticipates publication of the “Review” about developed for veterans returning from combat or three times annually. Four were issued in Calendar peacekeeping missions, and how to access these Year 2001, and the three were released in 2002. This programs. issue was completed in late October 2003 and does not The publication provides information about Iraq, and include developments that occurred after that time. about the 1990-91 War and its aftermath. It describes Comments or questions concerning the content of VA's program to respond to the needs of the veterans the “Review” are encouraged. Suggestions and ideas of the 1990-91 conflict, including medical treatment, for future issues of the newsletter should be sent to scientific research, and disability compensation. It the Gulf War Review, c/o Donald J. Rosenblum, also describes the health risk to U.S. service members Deputy Director, Environmental Agents Service serving in Iraq during 2003, including environmental (131), VA Central Office, 810 Vermont Avenue, health hazards, infectious diseases, preventive N.W., Washington, DC 20420. Please do not send measures, pesticide exposure, and deployment stress. comments or questions to the Austin Automation The brochure also discusses deployment-related health Center. Officials there routinely send the questions/ effects. comments to the Environmental Agents Service in The publication provides a great deal of information Washington, DC. Writing to Austin will unnecessarily regarding health care resources for returning veterans, delay a response. including the 2-year special eligibility after leaving Requests for additional copies of this and/or future military service for VA hospital care, medical services, issues should also be sent to Mr. Rosenblum. A and nursing home care for any illness. It describes limited supply of the prior issues is available. Please VA’s War Related Illness and Injury Study Centers, specify the quantity and issue date requested. programs administered by VA’s Vet Centers, VA’s Questions about the Gulf War Registry examination Gulf War Web site, and Clinical Practice Guidelines should be directed to the environmental health for post-deployment health, jointly produced by VA coordinator (formerly known as the Registry and the Department of Defense. The brochure also Coordinator) or environmental health clinician identifies additional information resources. (formerly known as the Registry Physician) at the The publication can be found on VA web site nearest VA medical facility. The telephone number www.va.gov/gulfwar. Copies were also distributed can be found in the local telephone directory under to all VA medical centers in the Spring 2003. The the “U.S. Government” listings. Assistance is also brochure is also known as Information Bulletin 10-166. available from the toll-free VA Gulf War Helpline: 1-800-749-8387. VA benefit offices also have a great deal of information about VA benefit programs. The national toll-free telephone number is 1-800-827-1000.

8 Address Changes and Duplicates Gulf War Health Registry Examination Statistics If this newsletter has your old address, please use this form to update our mailing list. Send the Here are some figures, as of the end of September completed form below to the Gulf War Review, 2003, regarding the VA’s Gulf War Registry Health Austin Automation Center (200/397A), 1615 Examination Program that started in 1992. Woodward Street, Austin, TX 78772-0001. If you Cumulative (1992-September 2003) have access to the Gulf War Review via the VA Web Total number of Gulf War veterans who have completed site www.va/gov/gulfwar and wish to discontinue examinations since the program began – 86,489 receiving a copy by regular postal mail, please indicate this on the form. If you are receiving more Total number of veterans tested for exposure to depleted than one copy of the newsletter, please let us know. uranium – 262 Thank you for providing your name, address, and Total number of dependents examination – 1,442 social security number; they are important to helping (Spouses 586, Children 856) us keep our mailing list accurate. Most Recent Month Check or circle the language that describes your Gulf War registry examinations -- 216 situation. NAS/IOM Gulf War Ongoing Health and ____My address has changed, and I would like to Environmental Exposure Assessments continue to receive the newsletter. (Continued on page 7) relationship between various potentially hazardous _____I am receiving more than one copy, but I only exposures experienced by Gulf War veterans and want to get a single copy. health problems in these veterans. _____I don’t need to get the newsletter by mail as I The institute of Medicine (IOM), a major component can read it at www.va.gov/gulfwar. of the NAS, has issued two Gulf War health reports to date. An additional two reports are in progress and _____Other (explain)______IOM officials are planning further reports. The reports ______can be seen at www.nap.edu. Please print your: The completed and ongoing reports are listed below. • September 2000 - Gulf War and Health, First Name ______Volume 1 : Depleted Uranium, Middle______Bromide, , Vaccines Last ______• February 2003 - Gulf War and Health, SSN: ______Volume 2 : Insecticides and Solvents New Street/RFD/Military Unit: • December 2003 - (anticipated date), -- Sarin ______Update (not exact date) • August 2004 - (anticipated date) -- Gulf War APO/FPO: ____ (Indicate which if applicable) and Health, Volume 3 : Oil Wells Fires, Jet City: ______Fuels Fuels, Tent Heater Fumes, Environmen- Alpha State/or APO/FPO Code: ___ tal Pollutants and Particulates (not exact title) ZIP Code: ______

9 Q’s & A’s – New Information Regarding Birth Defects However, the findings of this study may become The “Review” occasionally includes a questions- important if corroborated by a soon-to-be and-answers feature in which VA officials respond completed VA study.* VHA’s Environmental to inquiries from readers regarding the Gulf War Epidemiology Service is currently validating the experience, problems encountered by Gulf War findings from the VA National Survey of Gulf veterans and their families, and VA and other War veterans using birth records. The VA study Government programs designed to help veterans. should be completed later this year. Also, research is being conducted in Great A recent inquiry from CFS of Mebane, NC, asks Britain to assess the risk of birth defects in their about the possible relationship between military service population of Gulf War veterans’ offspring; the in the Gulf War and birth defects in their children” results of this study should be published later in It is not clear whether Gulf War military service 2003. We are hopeful that ongoing research will and birth defects are linked. But several studies are provide firm answers to the questions raised. addressing this concern. Dr. Mark A. Brown, Director, The possibility of an increased risk of birth Environmental Agents Service, responds to this defects is a difficult and emotional issue for inquiry: military veterans because the consequences of a A great deal of information is now known birth defect can be so terrible. The Department about this matter, including a recent scientific of Veterans Affairs recognizes the importance of publication on birth defects among Gulf War the new Navy study of birth defects, and that it veterans entitled “Prevalence of Birth Defects addresses a concern that many combat veterans Among Infants of Gulf War Veterans in Arkansas, have expressed. While it is not a definitive study, Arizona, California, Georgia, Hawaii, and it raises serious questions that must and will be Iowa, 1989–1993,” Araneta et al., Birth Defects addressed by research. Research (Part A) 67:246–260, 2003. The study At present, the Department of Veterans Affairs was conducted at the Naval Health Research does not have the authority to provide medical Center in San Diego, CA, and was funded by the treatment to the children of Gulf War veterans. U.S. military. It reported greater rates of five birth In those cases where VA provides treatment, for defects out of the 48 studied defects among infants example to children with spina bifida born to of male and female Gulf War veterans, including Vietnam veterans, it required special legislative certain heart and kidney defects. That study also authority from Congress. reported greater rates of a birth defect in which Questions on Gulf War health issue should be the urethra terminates in an abnormal position in sent to Mr. Donald J. Rosenblum, Deputy Director, the penis, but only among infants conceived by Environmental Agents Service (131), ATTN GWR – female Gulf War veterans. However, the overall Q’s and A’s, 810 Vermont Avenue, N.W., Washington, rate of birth defects was not higher among Gulf DC 20420. War veterans. ------The Navy researchers acknowledged in their *Note: Dr. Brown's remarks pre-dated Dr. Han publication certain limitations of their study, Kang’s findings discussed in the article on the including an inability to determine if the excess Research Advisory Committee. Preliminary results, birth defects were caused by inherited or announced by Dr. Kang, found that male Gulf War environmental factors, or were due to chance from veterans reported having infants with likely birth various causes. defects at twice the rate of non-veterans. Furthermore, female Gulf War veterans were almost three times Also, several previous similar large studies have more likely to report children with birth defects than shown no statistically significant increase in birth their non-Gulf counterparts. The numbers changed defects among children born to Gulf War veterans. somewhat with medical records verification. However, The DoD-funded, Navy study does not provide Dr. Kang and his colleagues concluded that the risk of solid proof that children of Gulf War veterans are birth defects in children of deployed male veterans still at higher risk of birth defects because the results was about 2.2 times that of non-deployed veterans. His could easily have resulted from chance alone. research is currently undergoing peer review.

10 Where to Get Help Active duty military personnel with questions DoD has changed its “Incidents Hotline” to the or concerns about their service in the “Direct Veterans Hotline” to more accurately reflect - contact your or call the the work done by the Hotline’s contact managers. The Department of Defense (DoD) Gulf War Veterans’ new toll-free number is 1-800-497-6261. Hotline (1-800-796-9699) for an examination. For additional information about VA’s program Gulf War veterans with concerns about their initiatives, see VA’s Gulf War veterans’ illnesses health - contact the nearest VA medical center. The home page at www.va.gov/gulfwar. telephone number can be found in the local telephone Gulf War veterans who encounter difficulties directory under Department of Veterans Affairs at a VA medical facility can contact the “patient in the “U.S. Government” listings. A Gulf War advocate” at that facility for assistance in resolving Registry examination will be offered. Treatment the problem. The medical center telephone operator will be provided to eligible veterans. The VA Gulf should have the telephone number. War Information Helpline can also provide the latest information and assistance. The toll-free telephone Representatives of veterans service organizations, number is 1-800-PGW-VETS (1-800-749-8387). including the American Legion (1-800-433-3318), Veterans of Foreign Wars of the Gulf War veterans in need of marital/family (1-800-VFW-1899), Disabled American Veterans counseling - contact the nearest VA medical center (1-877-426-2838), etc., have been very helpful to Gulf or VA vet center. For additional information, call the War veterans, especially veterans who are seeking Gulf War Information Helpline at 1-800-PGW-VETS disability compensation. (These organizations are (1-800-749-8387). cited as examples. There are many other excellent Gulf War veterans seeking disability compensation organizations. VA does not endorse or recommend any for illnesses incurred in or aggravated by military one group over another.) service - contact a Veterans Benefits Counselor at the County Veterans Service Officersalso have been nearest VA regional office or health care facility at of great help to many military veterans, including those 1-800-827-1000, or call the VA Gulf War Information who served in the Gulf War, who are seeking benefits Helpline at 1-800-PGW-VETS (1-800-749-8387). they earned through their service to the Nation. Gulf War veterans seeking participation for their spouses or children in the VA-funded health For additional Federal benefit information, see examination program for spouses and children - call VA’s Federal Benefits for Veterans and Dependents the VA Gulf War Information Helpline at 1-800- booklet. It is updated annually to reflect changes in PGW-VETS (1-800-749-8387). Veterans interested in law and policies. It is available for purchase from the alternative self-funded examination for spouses or the U.S, Government Printing Office, Superintendent children - contact the Gulf War Registry Coordinator of Documents, Washington, DC 20402,Web site: at the nearest VA medical center for forms and bookstore.gpo.gov. VA’s World Wide Web pages are information. updated throughout the year to present the most current information. The VA home page (www.va.gov) Gulf War veterans interested in learning about the contains links to selections on compensation and wide range of benefit programs administered by VA pension benefits, health care benefits and services, - contact a Veterans Benefits Counselor at the nearest burial and memorial benefits, etc. VA regional office or health care facility at1-800-827- 1000, or call the VA Gulf War Information Helpline at 1-800-PGW-VETS (1-800-749-8387).

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